Brookdale Westerville

Based on observation and interview, the facility failed to ensure previously opened food items were labeled and dated to protect against spoilage and contamination. This had the potential to affect all 34 residents receiving food from the kitchen at the facility. The facility had a census of 34.

Findings include:

Observation on 04/01/26 at 8:30 A.M. of the kitchen refrigerator revealed a white creamy substance wrapped in plastic wrap, it was unlabeled and undated and a previously opened bottle of a brown product was undated.

Observation on 04/01/26 at 8:32 A.M. of the freezer revealed a previously opened frozen meat product was unlabeled and undated.

Observation on 04/01/26 at 8:35 A.M. of the pantry revealed a previously opened circular food object that Dining Services Coordinator #400 identified as pasta was unlabeled and undated.

Observation on 04/01/26 at 8:36 A.M. of the pantry revealed a yellow powder in a bag was unsealed, unlabeled and undated. Dining Services Coordinator #400 removed item from the pantry and disposed of it.

During an interview on 04/01/26 at 8:42 A.M., Dining Services Coordinator #400 stated that all previously opened food items should be labeled and dated. They stated some people who work in the kitchen do not always label and date previously opened items.

Based on observations, staff interview, and review of facility policy, the facility failed to ensure a clean and sanitary supply of eating and drinking utensils when the dishwasher was used to wash dishes at unsafe temperatures. This had the potential to affect all 34 residents who eat food from the facility kitchen. Findings include: Observation of the dishwashing wash temperature cycle on 04/01/26 at 8:30 A.M. revealed that the wash cycle water temperature reached a maximum of 138 degrees Fahrenheit. A follow up observation of two dishwashing wash temperature cycles on 04/01/26 at 1:50 P.M. revealed that the wash cycle water temperature reached a maximum of 138 degrees Fahrenheit. The manager was completing the dishwashing cycle for all of the lunch dishes at this time. An interview with Dining Services Coordinator #400 on 04/01/26 at 1:52 P.M. confirmed that the dishwasher's wash cycle water temperature did not reach the required wash cycle temperature of 150 degrees Fahrenheit. Dining Services Coordinator #400 confirmed that the dishwasher was a high temperature machine. Review of the facility policy titled, Washing and Sanitizing DishesBased on observations, staff interview, and review of facility policy, the facility failed to ensure a clean and sanitary supply of eating and drinking utensils when the dishwasher was used to wash dishes at unsafe temperatures. This had the potential to affect all 34 residents who eat food from the facility kitchen.

Findings include:

Observation of the dishwashing wash temperature cycle on 04/01/26 at 8:30 A.M. revealed that the wash cycle water temperature reached a maximum of 138 degrees Fahrenheit.

A follow up observation of two dishwashing wash temperature cycles on 04/01/26 at 1:50 P.M. revealed that the wash cycle water temperature reached a maximum of 138 degrees Fahrenheit. The manager was completing the dishwashing cycle for all of the lunch dishes at this time.

An interview with Dining Services Coordinator #400 on 04/01/26 at 1:52 P.M. confirmed that the dishwasher's wash cycle water temperature did not reach the required wash cycle temperature of 150 degrees Fahrenheit. Dining Services Coordinator #400 confirmed that the dishwasher was a high temperature machine.

Review of the facility policy titled, Washing and Sanitizing Dishes

Based on review of the facility's fire drills, staff interview, and review of facility policy, the facility failed to conduct fire drills once every three months on each shift, and also failed to evacuate residents twice per shift on an annual basis. This had the potential to affect all 34 residents residing in the facility. Findings include: 1. Review of the facility fire drills revealed that first shift fire drills were conducted on 07/31/25, 09/24/25, 10/17/25, 12/01/25, and 01/03/26. Second shift fire drills were conducted on 08/19/25, 02/21/26, and 03/26/26. Third shift fire drills were conducted on 06/18/25 and 11/30/25. The first, second, and third shift fire drills were not completed once every three months for each shift per the regulation. 2. Review of the facility fire drills revealed that residents were evacuated on 09/24/25 (a first shift fire drill), and on 03/26/26 (a second shift fire drill). The other monthly fire drills indicated that evacuations were not applicable. An interview with Maintenance Technician #200 on 04/01/26 confirmed that he did not conduct fire drills once per shift every three months and that he did not evacuate residents twice per shift annually. Review of the facility policy titled Fire DrillsBased on review of the facility's fire drills, staff interview, and review of facility policy, the facility failed to conduct fire drills once every three months on each shift, and also failed to evacuate residents twice per shift on an annual basis. This had the potential to affect all 34 residents residing in the facility.

Findings include:

1. Review of the facility fire drills revealed that first shift fire drills were conducted on 07/31/25, 09/24/25, 10/17/25, 12/01/25, and 01/03/26. Second shift fire drills were conducted on 08/19/25, 02/21/26, and 03/26/26. Third shift fire drills were conducted on 06/18/25 and 11/30/25. The first, second, and third shift fire drills were not completed once every three months for each shift per the regulation.

2. Review of the facility fire drills revealed that residents were evacuated on 09/24/25 (a first shift fire drill), and on 03/26/26 (a second shift fire drill). The other monthly fire drills indicated that evacuations were not applicable.

An interview with Maintenance Technician #200 on 04/01/26 confirmed that he did not conduct fire drills once per shift every three months and that he did not evacuate residents twice per shift annually.

Review of the facility policy titled Fire Drills

Based on record review, observation, staff interview and facility policy review the facility failed to ensure a personal pet was up to date on required vaccines and yearly veterinary examination. This affected one resident (Resident #32) but had the potential to affect the 10 residents residing on memory care. The facility census was 34.

Findings Include:

Review of the medical record for Resident #32 revealed initial admission date 02/13/24. Resident #32 was then moved to the memory unit 06/25, with diagnoses including but not limited unspecified dementia, anxiety, depression disorder, delusional disorders, and cognitive communication deficit.

Review of the service plan for Resident #32 revealed Resident #32 required standby assist with dressing and bathing. Resident #32 received assistance with toileting and was incontinent of bladder. Further review revealed Resident #32 had a pet cat residing in her room and required assistance from staff for caring for the cat including cleaning the litter box and feeding the cat related to Resident #32 was not fully capable in performing pet care tasks.

Review of the Certification of Vaccine form dated 06/30/24 from the veterinarian revealed the cat received the rabies vaccination on 02/20/24, the Feline Leukemia booster and the Feline Viral Rhinotracheitis, Calicivirus, and Panleukopenia (FVRCP) on 06/30/24. The cat had not had its annual veterinarian check for 2025.

Observation on 08/20/25 at 9:45 A.M. revealed in Resident #32's room an uncovered litter box sitting on the floor underneath the bathroom sink. There was a plate sitting on the countertop with a moderate amount of canned cat food on the plate. Resident #32's room had a strong odor of cat urine noted. The cat was not visible at the time of the observation and Resident #32 was in the unit lounge area, participating in activities.

Interview on 08/20/25 at 9:50 A.M. with Care Partner (CP) #115 revealed the staff cared for Resident #32's cat with routine litter box cleaning and issuing the cat has fresh water and food daily. CP #115 stated the cat did not leave Resident #32's room and the cat would hide from staff and/or visitors when entering the room.

Interview on 08/20/25 at 10:25 A.M. with the Director revealed Resident #32's son was to be coming into the facility to help care for the cat, was responsible for keeping up to date with the cat's annual veterinary exam and vaccine requirements. The Director confirmed the cat had not been evaluated by a veterinary since 2024. The Director stated the facility did not notify Resident #32's son when the cat was due for the veterinary exam.

Reviewed the facility's policy titled Pet Policy dated 09/1997 revealed Any living animal in the community must have regular examinations and vaccinations by a licensed veterinarian and be certified by a veterinarian to be free of diseases transmittable to humans, as applicable.

This violation represents non-compliance investigated under Complaint Number OH00166227.

Based on employee file review, staff interview, facility policy review, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure five employees were appropriately screened for tuberculosis (TB) per CDC guidelines. This had the potential to affect all 36 residents residing in the facility. Findings include: 1. Review of the employee record for Caregiver #131 revealed the date of hire was 10/28/24. Review of the TB Test Skin Test Report and Questionnaire for Caregiver #131 dated 10/09/24 revealed a first step Mantoux (TB) test was conducted on 10/09/24 and read on 10/11/24. The second step of the TB skin test form was blank. 2. Review of the employee record for Licensed Practical Nurse (LPN) #191 revealed the date of hire was 09/30/24. Review of the TB Screening Form for LPN #191 revealed a first step Mantoux (TB) test was conducted on 09/23/24 and read on 09/25/24. There was no evidence that the second step of the TB skin test was completed. 3. Review of the employee record for Caregiver #171 revealed the date of hire was 01/23/25. Review of a document titled TB Test Placement for Caregiver #171 revealed the first TB skin test was administered on 01/13/25 and read on 01/15/25. There was no evidence that a second TB skin test was administered. Review of the facility policy 'Tuberculosis Exposure Control Plan' revised January 2025 revealed initial TB screening for associates should be completed using the two-step Mantoux skin test prior to hire date. 4. Review of the employee record for Caregiver #126 revealed the date of hire was 03/27/24. Review of the employee record for Caregiver #126 revealed the TB Surveillance Questionnaire was completed on 07/31/24, four months after the employee's anniversary. 5. Review of the employee record for Caregiver #129 revealed the date of hire was 01/12/24. There was no evidence in the file for Caregiver #129 that an annual tuberculosis screening questionnaire was completed. Interview on 05/22/25 at 5:30 P.M. with Administrative Assistant #122 confirmed that the employee records for LPN #191, Caregiver #171 and Caregiver #131 did not have the second step of the tuberculosis skin test completed. She was unaware that completing the two step Mantoux test was in the facility's TB control policy. She confirmed that Caregiver #126 had completed the annual TB assessment four months past their anniversary and that Caregiver #129 did not have annual tuberculosis symptom screening documentation in their file. Interview on 05/22/25 at 5:30 P.M. with Infection Preventionist #115 confirmed they had been conducting annual screenings at the same time yearly and that it would be more accurate to schedule annual screening tied to the employee's start date. Review of the facility policy titled Tuberculosis Control Plan revised December 2022 revealed the annual TB Surveillance Questionnaire should be conducted annually for all personnel and reviewed by a nurse. Review of the CDC guidelines titled Baseline Tuberculosis Screening and Testing for Health Care PersonnelBased on employee file review, staff interview, facility policy review, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure five employees were appropriately screened for tuberculosis (TB) per CDC guidelines. This had the potential to affect all 36 residents residing in the facility.

Findings include:

1. Review of the employee record for Caregiver #131 revealed the date of hire was 10/28/24.

Review of the TB Test Skin Test Report and Questionnaire for Caregiver #131 dated 10/09/24 revealed a first step Mantoux (TB) test was conducted on 10/09/24 and read on 10/11/24. The second step of the TB skin test form was blank.

2. Review of the employee record for Licensed Practical Nurse (LPN) #191 revealed the date of hire was 09/30/24.

Review of the TB Screening Form for LPN #191 revealed a first step Mantoux (TB) test was conducted on 09/23/24 and read on 09/25/24. There was no evidence that the second step of the TB skin test was completed.

3. Review of the employee record for Caregiver #171 revealed the date of hire was 01/23/25.

Review of a document titled TB Test Placement for Caregiver #171 revealed the first TB skin test was administered on 01/13/25 and read on 01/15/25. There was no evidence that a second TB skin test was administered.

Review of the facility policy 'Tuberculosis Exposure Control Plan' revised January 2025 revealed initial TB screening for associates should be completed using the two-step Mantoux skin test prior to hire date.

4. Review of the employee record for Caregiver #126 revealed the date of hire was 03/27/24.

Review of the employee record for Caregiver #126 revealed the TB Surveillance Questionnaire was completed on 07/31/24, four months after the employee's anniversary.

5. Review of the employee record for Caregiver #129 revealed the date of hire was 01/12/24. There was no evidence in the file for Caregiver #129 that an annual tuberculosis screening questionnaire was completed.

Interview on 05/22/25 at 5:30 P.M. with Administrative Assistant #122 confirmed that the employee records for LPN #191, Caregiver #171 and Caregiver #131 did not have the second step of the tuberculosis skin test completed. She was unaware that completing the two step Mantoux test was in the facility's TB control policy. She confirmed that Caregiver #126 had completed the annual TB assessment four months past their anniversary and that Caregiver #129 did not have annual tuberculosis symptom screening documentation in their file.

Interview on 05/22/25 at 5:30 P.M. with Infection Preventionist #115 confirmed they had been conducting annual screenings at the same time yearly and that it would be more accurate to schedule annual screening tied to the employee's start date.

Review of the facility policy titled Tuberculosis Control Plan revised December 2022 revealed the annual TB Surveillance Questionnaire should be conducted annually for all personnel and reviewed by a nurse.

Review of the CDC guidelines titled Baseline Tuberculosis Screening and Testing for Health Care Personnel

Based on observation, staff interviews, and facility policy review, the facility failed to ensure water dispenser in the memory care unit distributed water at a safe temperature for residents with cognitive decline. This had potential to affect the five independently mobile residents (#20, #21, #23, #24 and #27) residing in the memory care unit. The facility census was 36.

Findings include:

Observation on 05/22/25 at 2:26 P.M. of the memory care kitchen area (with open access for residents) revealed a freestanding water dispenser. The dispenser had a button for cold water and a button for hot water. Caregiver #178, who was present during observation, pressed the hot water button and steaming hot water was dispensed into a cup. A thermometer was utilized and Caregiver #178 verified the dispensed water was a temperature of 180 degrees Fahrenheit.

Interview on 05/22/25 at 2:26 P.M. with Caregiver #178 revealed that while she had not seen residents access the hot water from the dispenser, she noted that there were several residents who would be able to access it.

Interview on 05/22/25 at 2:30 P.M. with Wellness Director #115 revealed he was surprised that the hot water in the dispenser was turned on and confirmed that it was a safety hazard for the memory care residents.

Interview on 05/22/25 at 2:35 P.M. with Wellness Director #115 revealed he didn't know how long the hot water dispenser in the memory care had been active. He noted that it shouldn't be that hot and that he would get it fixed as soon as possible. The Wellness Director confirmed there were five independently mobile residents in the memory care unit.

Interview on 05/22/25 at 2:58 P.M. with the Executive Director confirmed they had turned off the hot water dispenser in the memory care. He shared that he had contacted the vendor who supplied the water dispenser unit and they would be adjusting the water to a safer temperature.

Review of facility policy titled Water Temperature revised January 2023, revealed water temperatures in resident areas should be between 105 and 120 degrees Fahrenheit.

Based on record review, staff interview, and facility policy review the facility failed to conduct annual Tuberculosis (TB) assessments. This had the potential to affect 31 of 31 residents residing in the facility.

Findings include:

Review of the Background Check Log revealed the date of hire for Caregiver #110 was 02/14/23 and the date of hire for Caregiver #114 was 04/31/23.

Review of the personnel file for Caregiver #114 revealed a chest X-Ray was completed on 03/07/23 in lieu of a Mantoux (TB) test. There was no evidence of an annual TB assessment.

Review of the personnel file for Caregiver #110 revealed no evidence of initial or annual TB assessment.

Interview on 07/30/24 at 3:00 P.M. with Executive Director, verified there were no annual TB assessments completed for Caregivers #110 and #114.

Review of the policy 'Tuberculosis Control Plan' revised December 2022 revealed the annual TB Surveillance Questionnaire should be conducted annually for all personnel and reviewed by a nurse.

Based on observation, interview, and review of the facility policy the facility failed to ensure food was prepared, stored, and served in a sanitary manner. This had the potential to affect 31 of 31 residents who consumed food from the kitchen. The facility census was 31.

Findings include:

Observation on 07/30/24 at 9:10 A.M. revealed the following sanitation concerns: multiple cupboards and areas of the wall were covered in food splatter, the oven vents had a buildup of grease, and the floor of the dry storage room was covered in food and plastic debris including a plastic spoons and bits of onion. Additionally, on the stove top rested a full-sized stainless steamtable pan that appeared to be charred as it was completely black on the outside with pieces of the charred material flaking off. There was an identically black and peeling pan on shelf above the stove, extending off the shelf and over the stove.

Observation on 07/30/24 from 11:55 A.M. to 12:40 P.M. revealed the following concerns:

a. Meal temperatures were not obtained in a sanitary manner. Cook #113 was observed obtaining temperatures prior to serving the residents outside of the memory care unit. He took the temperature of the soup with a thermometer and then used his glove to wipe the thermometer clean. He then obtained the temperature of the broccoli with the same thermometer and wiped it clean using his glove. Cook #113 then used the same thermometer to obtain the temperature of the pasta sauce.

b. Food temperatures were not appropriately obtained prior to serving food to the residents outside of the memory care unit. Cook #113 checked the temperature of the dessert (cheesecake) it was 60 degrees Fahrenheit. Cook #113 acknowledged that the temperature was too warm, he returned the cheesecake to the fridge and began serving lunch. During meal service, staff took the cheesecake from the fridge and served it without checking that it was at an appropriate temperature.

c. Cook #113 did not appropriately wash his hands and change his gloves. Cook #113 was observed washing his hands and donning gloves prior to checking the temperature of the food. He then began meal service to the main assisted living dining room without changing his gloves or washing his hands. In that time frame he was observed opening the refrigerator, touching his clothes, touching his glasses, touching various counter tops, putting his hands on his hips, and touching the trash can. During meal service Cook #113 was observed touching the inside of the bowls and plates the food was served on and touching the noodles after they were on resident's plates. Cook #113 did not change his gloves or wash his hands until he was done serving the dining room.

. The kitchen was not maintained in a clean and sanitary manner. The concerns observed at 9:00 A.M. remained. The charred stainless-steel pan remained on the shelf above the stove. It extended over the shelf and hung over the pot with soup and the bowls the soup was served in. Additionally, the hot cart the memory care food was transported in had food splatter throughout the container. The wall behind the freezer had a thick buildup of dust trailing almost up to the ceiling. Finally, the floor underneath the oven was covered in food splatters and food debris.

Interview on 07/30/24 from 11:55 A.M. to 12:40 P.M. with Cook #113 verified he had not appropriately cleaned his thermometer between obtaining the temperature of food. Cook #113 additionally verified the temperature of the cheesecake was not checked again to confirm it was at an appropriate temperature. While washing his hands prior to beginning room trays, Cook #113 verified it was his first-time changing gloves and washing his hands since the beginning of the observation.

Interview on 07/30/24 from 11:55 A.M. to 12:40 P.M. with Dining Services Coordinator #105 verified the observations of the kitchen not being maintained in a sanitary manner. She reported the pan above the stove was not usually there but placed on the stove to hold items.

Review of the facility policy 'Food Storage' revised June 2024 revealed all storerooms and walk-ins should be maintained free from dirt, dust, insects, rodents or other potential sources of contamination.

Review of the facility policy 'Food and beverage Temperature' reviewed February 2024 revealed, food and beverage temperatures during meal service should be taken at the beginning of the meal service and once 30 minutes into service. If any temperatures were not within the acceptable range, the food or beverage must be reheated or discarded. It did not address what to do with food items that were supposed to be maintained at 40 degrees Fahrenheit or below.